Michael Gordon, MD, MSc, FRCPC, FRCP Edin, Medical Program Director, Palliative Care Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.
Kayi Li, BHSc, medical student, University of Toronto, Toronto, ON.

Osteoporosis is a systemic disease resulting in bone fragility and increased risk of fractures. For optimal prevention, the literature increasingly supports the combined use of education on nutrition, lifestyle, and exercise. Currently, multidisciplinary, multimodal initiatives are rarely implemented in the community. The POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) program in Toronto, Ontario, strives to empower individuals with osteoporosis with diverse cultural backgrounds to sustain healthy behaviours for self-management of their condition. This article provides a description of the POWER program philosophy, as well as a preliminary evaluation to assess its benefits and potential for further expansion and adaptation.
Key words: osteoporosis, management program, cultural differences, education, health beliefs.

M. Bachir Tazkarji, MD, CCFP, CAQ Geriatric Medicine, Lecturer, Family Medicine Department, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.

As the population is aging, physicians from all specialties are expected to see more older adults at their outpatient practices and in the acute settings. Abdominal pain remains one of the most common and potentially serious complaints that emergency physicians encounter. Vascular pathology should be considered early in the diagnostic course of all older adults who have abdominal pain because the time for intervention is critical.
Key words: abdominal pain, older adults, management of acute abdominal pain.

Ellen Grober, PhD, Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.

We have developed and validated a cost-effective case finding tool for early dementia in primary care that consists of two stages: a rapid dementia screening test administered to all patients over the age of 65 and a second stage to identify memory impairment administered to patients who fail the first stage. The Alzheimer’s Disease Screen for Primary Care (ADS-PC) had high sensitivity and specificity for early dementia and higher sensitivity for AD, and distinguished AD from non-AD dementias. The ADS-PC outperformed the MMSE and worked equally well in African-American and Caucasian primary care patients and in patients that differed in educational level.
Key words: Alzheimer’s disease, early dementia, mass screening, primary health care, neuropsychological tests.

Bailus Walker Jr., PhD, MPH, Department of Community and Family Medicine, College of Medicine, Howard University, Washington, DC, USA.
Charles Mouton, MD, MS, Department of Community and Family Medicine, College of Medicine, Howard University, Washington, DC, USA.

In the late 1990s, it became increasingly clear that air pollution, even at the lower ambient concentrations prevalent in many urban areas, is associated with increased mortality and other serious health effects. More recently, considerable research has focused on particulate air pollution as studies have linked a growing number of health effects to fine particles. Hundreds of studies now indicate that breathing fine particles discharged by vehicles, factories, and power plants can trigger a cardiac event and exacerbate respiratory disease in vulnerable populations. Older adults are one subgroup considered more susceptible to the effects of airborne particles. This sensitivity can be attributed to a number of factors including loss of pulmonary functional reserve and compensation due to age or disease. Although a number of mechanisms have been proposed to explain the adverse impact of particles on cardiovascular health, many questions remain. Their answers will require further transdisciplinary research.
Key words: heart disease, air pollution, smog, particulates, older adults.

Victoria J. Scott, PhD, RN, Clinical Assistant Professor, School of Population and Public Health; Senior Advisor, Falls & Injury Prevention, BC Injury Research & Prevention Unit and Ministry of Healthy Living and Sport, Victoria, BC.
S. Johnson, PhD, Professor, Faculty of Kinesiology and Health Studies, University of Regina, SK.
J.F. Kozak, PhD, Assistant Professor, School of Population and Public Health, University of British Columbia; Director of Research Centre for Healthy Aging, Providence Health, Vancouver, BC.
Elaine M. Gallagher, PhD, RN, Professor, School of Nursing; Director, Centre on Aging,
University of Victoria, Victoria, BC.

Approximately one in two older adults living in long-term care (LTC) settings sustains a fall every year, resulting in significant human suffering and treatment costs. The complex set of factors that contribute to fall risk among this population demands a multidisciplinary approach to this problem, with physicians playing a pivotal role in risk assessment, prevention, and management. We describe a study where facility personnel from five LTC sites were trained in the use of a standardized surveillance tool to track falls, fall injuries, and contributing factors over 16-months. Using a pre-/post-test design, interventions included a multidisciplinary, evidence-based approach to fall risk assessment and monitoring, environmental modifications, exercise, and education strategies. Interventions by a multidisciplinary team, including physicians, were successful in reducing fall-related injuries and relatively successful in reducing the rate of falls among LTC residents. Further study is needed over a longer period of time, using a randomized control trial, to determine the effectiveness of specific interventions and to generalize findings to the larger population of LTC residents.
Key words: fall prevention, long-term care, multidisciplinary approach, older adults.

Christopher Patterson, MD, FRCPC, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON.
John W. Feightner, MD, MSc, FCFP, Chair, Canadian Task Force on Preventive Health Care; Department of Family Medicine, Faculty of Medicine, University of Western Ontario, London, ON.

The ultimate aim of critical appraisal is to decide whether the conclusions of an article are helpful in the prevention or management of illness in your patients. This requires the article to be relevant to your practice and to contain sufficient information to determine if the conclusions are supported by the evidence within it. We offer approaches to the appraisal of different types of publications addressing primary and secondary prevention.
Key words: prevention (primary, secondary), clinical research, critical appraisal, clinical practice guidelines.

Mazen S. Bader, MD, FRCPC, MPH, Department of Medicine, Division of Infectious Diseases, Memorial University of Newfoundland and Labrador, St. John’s, NL.
Daniel Hinthorn, MD, FACP, Department of Medicine, Division of Infectious Diseases, University of Kansas Medical Center, Kansas City, KS, USA.

Preventive health interventions are key to maintaining the health and good function of older adults. Despite being safe and a highly effective method of preventing certain infectious diseases, vaccination rates among older adults continue to lag behind national goals. Vaccines for older adults can be divided into three categories: those that are required for all older adults, those that may be required for special circumstances, and those that are required for travel. Physicians should be familiar with the indications, contraindications, and adverse effects of commonly used vaccines among older adults. This article will focus only on the vaccines required for all older adults.
Key words: vaccines, older adults, influenza, pneumococcal vaccine, herpes zoster, tetanus.

Catherine Agbokou, MD, MSc, Service de Psychiatrie Adulte, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France.
Emmanuel Cognat, MD, Service de Psychiatrie et de Psychologie Médicale, Hôpital Saint-Antoine, Université Pierre et Marie Curie, Paris, France.
Florian Ferreri, MD, MSc, Service de Psychiatrie et de Psychologie Médicale, Hôpital Saint-Antoine, Université Pierre et Marie Curie, Paris, France.

Differentiating between Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB) is a difficult issue for many clinicians. To date, these diseases share most of their clinical, neuropathological, and management features. Therefore, PDD and DLB are considered by some authors to be the two extremities of a single spectrum disease named Lewy body diseases. Nevertheless, specific diagnostic criteria now exist for each disease and specific diagnosis remains of interest in clinical practice. In this article, we summarize features and diagnostic criteria of both PDD and DLB, compare them, and examine their treatment options.
Key words: Parkinson’s disease dementia, dementia with Lewy bodies, Lewy body disease, movement disorders, dementia, treatment.

Sander Veldhuyzen van Zanten, MD, PhD, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB.

Dyspepsia is defined as an epigastric pain or discomfort thought to originate in the upper gastrointestinal (GI) tract. There is discussion, especially in uninvestigated patients, about whether gastroesophageal reflux disease (GERD) can be separated from dyspepsia. If heartburn and regurgitation are the dominant symptoms, GERD is the likely diagnosis. Among older adults, more severe esophagitis is often seen, while at the same time patients report less severe symptoms. The use of nonsteroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), and cyclo-oxygenase 2 selected inhibitors is associated with an increased frequency of dyspepsia and, more importantly, ulcers and upper GI bleeding. In new-onset dyspepsia among older adults, endoscopy should be considered given the increased risk of an upper GI malignancy. Among individuals taking NSAIDs, the medication should ideally be discontinued if it is thought to be the cause of dyspepsia. For NSAID prophylaxis, there is evidence that use of a once-daily proton pump inhibitor or misoprostol 200 µg two to four times per day decreases the risk of upper GI ulcers. NSAID prophylaxis is underused among older adults taking non-ASA NSAIDs, and the reasons for this and its consequences require further study.
Key words: dyspepsia, gastroesophageal reflux disease, NSAIDs, ASA, H. pylori.

Alissa R. Segal, PharmD, CDE, Associate Professor, Massachusetts College of Pharmacy and Health Sciences; Clinical pharmacist, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.
Medha N. Munshi, MD, Assistant Professor, Harvard Medical School; Director of Joslin
Geriatric Diabetes Program, Joslin Diabetes Center; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.

The aging of the population and increasing prevalence of diabetes are worldwide phenomena that require a better focus on challenges of diabetes management in older adults. We now understand the benefits of tight glycemic control and have an armament of agents to achieve such a feat. However, in an aging population, balance must be sought between the goals of glycemic control and those of overall health status, including quality of life. Insulin therapy, in particular, requires significant self-care abilities. Insulin therapy can be used safely and effectively if diabetes management plans are formulated with consideration of the clinical, functional, and psychosocial contexts of an older adult.
Key words: diabetes, older adults, insulin therapy, geriatrics, glycemic control.